I have to do two care plans on a pt I have never seen just the chart.
each care plan must have 2 short term and 2 long term goals
81 y/o w/m
diag- periventricular leukoencephalopathy with brain atropy and calcified right vetebral artery
muscle weakness ( dressing, balance, gait and strength tested fair/poor), episodes of syncope and collapse, dysphagia (occasionally)
hx of seizure disorder.
I was thinking of using-
Risk for fall r/t PVL aeb muscle weakness, episodes of sycope and collapse, hx of seizure disorder
STG- Pt will not fall during my 8 hour shift
STG- Pt will be learn how to use assistive devices such as wheelchair and pull bars by the end of my 8 hour shift
LTG-Pt will be able to transfer from bed to wheelchair with min. or no assistance by the end of 3 months.
LTG- ?????? (not sure)
Impaired Verbal Communication r/t PVL aeb muscle weakness, poor oral motor skills, dysphagia
STG- Pt will be able to use alternative methods of communication effectively by the end of my 8 hour shift
STG- Pt will demonstrate understanding by nodding head yes/no by the end of my 8 hour shift
LTG- Pt will be able to say simple words such as yes, no, help, in the next 2 months
LTG- ???? (not sure)
please let me know if the above is ok and any suggestions would be helpful